Chronic Heart Failure

Question 1

Patient is on:
Bisoprolol 5 mg OD
Spironolactone 25 mg OD
Frusomide 50 mg

What condition do they most likely have….

a. Angina
b. Atrial fibrillation
c. Hypertension
d. Congestive heart failure

Answer 1

(d) answer

Question 2

What is chronic heart failure?

Answer 2

Heart becomes too weak to pump efficiently, thus it cannot meet the metabolic demands of the body.

Question 3

Causes of CHF (think failure).

Answer 3

Fatty heart valves makes the heart work very hard.
Arrythmias- atrial fibrillation or tachycardia.
Infarctions- myocardial.
Lineage- congenital/family history.
Uncontrolled hypertension-stiffening o
Rvader- viruses
E- ecreational drugs

Question 4

Risk factors for CHF.

Answer 4

Diabetes.
Hypertension.
Myocardial infarction.
Thyroid disease

Question 5

How is CHF diagnosed and why are the test used.

Answer 5

Detailed clinical history and examination.
Elevated serum levels of NT-proBNP (above 400 ng/litres)- biomarker released when ventricles expand following excessive pressure.
Echocardiogram: Helps exclude valve disease, assess systolic and diastolic function of the left ventricle.
Chest X-ray- aids identification of an enlarged heart and any evidence of pulmonary crackles.

Question 6

What are the symptoms of left-sided heart failure and the ejection fraction (THINK DROWNING).

Answer 6

Left sided heart failure- patient present with pulmonary symptoms.
Dyspnoea- difficulty/laboured breathing aka ‘air hunger’
Rales/crackle in the heart.
Orthopena- identified by needs for extra pillows when sleeping.
Weakness- hear cannot contract out the cardiac output required.
Nocturnal paroxysmal dyspnea- waking at night with extreme breathing difficulty.
Increased heart rate- body attempts to pump backlog of blood out.
Nagging cough- which can get frothy/blood sputum- red flag
Gaining weight-attributed to excess fluid.

Question 7

Which one is not common symptom associated with left sided chronic heart failure
(a) dyspnea
(b) crackles in the chest
(c) increased heart rate
(d) Gaining weight
(e) increased abdomen size.

Answer 7

(e) increased abdomen size.

Question 8

What are the symptoms of right sided heart failure (SWELLING).

Question 9

Define Dyspnoea

Answer 9

Laboured breathing.

Question 10

Define Dyspnea

Answer 10

Shortness of breath- intense tightening in the chest.

Question 11

What lifestyle advice would you provide a CHF patient.

Answer 11

Smoking cessation
Daily weights-increases could be early warning sign of deterioration
Implement cardiac rehabilitation.
Reduced intake of caffeine, salt and alcohol.
Annual influenza vaccination and one-off pneumococcal vaccination.

Question 12

Which drugs would you NOT lower the dose in renal impairment (eGFR 30-45 ml/min/1.73 m2)
(a) Enoxaparin
(b) ACE-I/ARBs
(c) Spironolactone
(d) Digoxin
(E) Sacubitril/valsartan

Answer 12

(a) enoxaparin

Question 13

What medications should patient avoid in CHF.

Answer 13

NSAIDs- risk of nephrotoxicity.
Corticosteroids
Antacids- due to high sodium content.
Soluble analgesics- high sodium content.
Rate limiting calcium channel blocker
Antiarrythmic medicines (such as flecainide and dronedarone)
Piglitazone, metformin

Question 14

Why would you avoid effervescent and antacid preparation in CHF.

Answer 14

Due to high sodium content.

Question 15

If patient is presenting with signs of congestion what is the management plan.

Answer 15

Diuretics.
Frusemide 80mg

Question 16

What is the reduced ejection fraction patient must have to initiate management of it.
(a) 60%
(b) 50%
(c) 40%
(d) 80%

Answer 16

(c) 40%

Question 17

First line medication for treatment of HF with reduced ejection fraction.

Answer 17

ACEI* and BB started one at a time.
MDC trial showed there was a decrease in mortality when Beta-blockers where used because it blocked the effect of SNS stimulation

Question 18

If patient shows little/no improvement with ACE-I and beta blocker what is the next step.

Answer 18

Spironolactone/eplerone
In RALES trial there was a decrease in mortality in severe heart failure because it may be reducing fibrosis/remodelling of the heart.

Question 19

If patient latest echocardiogram showed ejection fraction is less than <35% what agent must be added or removed. Med history:
Ramipril 10mg OD
Bisoprolol 5 mg OD
Spironolactone 50 mg OD

Answer 19

ACE-I have to be stopped before initiating sacubitril/valsartan.

Question 20

If patient is in sinus rhythm but the latest echocardiogram showed ejection fraction is less than <35% and heart rate >70 bpm what agent must be added or removed
Ramipril 10mg OD
Bisoprolol 5 mg OD
Spironolactone 50 mg OD

Answer 20

Add Ivabradine.

Question 21

Select the best option for each scenario
a. Ramipril
b. Carvedilol
c. Frusemide
d. Amlodopine
e. Diltiazam
f. Digoxin
g. Hydralazine
h. Spironolactone

1. A 78-year-old male has been admitted to hospital with acute exacerbation of heart failure. The patient is found to have pulmonary oedema.
2. A 55-year-old African male has been admitted with heart failure with reduced ejection fraction already on beta blocker. What agent should he been on.
3. A 56-year-old male is already on first line treatment for heart failure, ACE-I, Beta blocker and mineralocorticoid. His heart failure is still worsening. What agent should be added.
4. A 45 year old female, who has been admitted into hospital with ascites. What agent should she be on.

Answer 21

1. (c) Loop diuretics are potent diuretics good for fluid reduction.
2. (g) ARBs/ACE-I are contraindicated in African/Caribbean descent.
3. (f) Digoxin
4. (h) Hyperaldosteronism plays a major role in the pathogenesis of ascites and contributes to resistance to loop diuretics. Therefore, the use of high doses of aldosterone antagonist (spironolactone up to 400 mg/day) is the main therapy to produce a negative sodium balance in cirrhotic patients with ascites.